Provider Demographics
NPI:1922369909
Name:PANGBORN, JESSICA (MS CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:PANGBORN
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15444 S GREENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-3460
Mailing Address - Country:US
Mailing Address - Phone:414-405-4403
Mailing Address - Fax:
Practice Address - Street 1:2011 CORONA RD STE 301
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-2548
Practice Address - Country:US
Practice Address - Phone:314-543-3860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011013608235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist